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Basis of tuberculosis

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  • This is the prompt slide for the TB Therapy section. This presentation will be presented at the local level by an Infectious Disease Practitioner or Pulmonary TB Control Officer. The Objectives of this presentation are to provide the attendees an understanding of the therapies used to treat TB and adverse events. The presentation is scheduled to be 30 minutes to include time for questions to be asked. Answers to some questions during the sessions may not be possible (time limitations or technical clarification needed). In such cases the speaker should request that the attendees write the question down and provide their FAX number, so that an answer to their question can be provided later. The opening statement should emphasize that prompt and efficient treatment of active tuberculosis is a key element in the prevention of spread of TB infection.
  • Therapy

    1. 1. TUBERCULOSIS TREATMENT Prompt and efficient treatment of active tuberculosis is a key element in the prevention of spread of TB infection.
    2. 2. TB TREATMENT PLAN ACET (CDC, ATS) <ul><li>For + culture do susceptibilities and </li></ul><ul><li>report results to Health Department </li></ul><ul><li>Initial trtmt. = 4 drugs; at least 2 mon. </li></ul><ul><li>INH, RIF, PZA, EMB or SM (unless </li></ul><ul><li>likelihood of INH resistance almost </li></ul><ul><li>non-existent) </li></ul><ul><li>Adjust Rx when susceptibilities known </li></ul><ul><li>DOT </li></ul>
    3. 3. TREATMENT OPTION 1 <ul><li>Initial Phase : </li></ul><ul><li>Daily INH, RIF, PZA & either EMB or </li></ul><ul><li>SM X 8 wks </li></ul><ul><li>May D/C EMB or SM if M . tb is </li></ul><ul><li>susceptible to INH & RIF </li></ul><ul><li>EMB or SM may not be necessary in </li></ul><ul><li>areas with documented INH </li></ul><ul><li>resistance <4% </li></ul>
    4. 4. TREATMENT OPTION 1 (Continued) <ul><li>Continuation Phase : </li></ul><ul><li>INH & RIF X 16 wks QD, 2 X wkly </li></ul><ul><li>or 3 X wkly </li></ul><ul><li>All regimens given 2 X wkly or 3 X </li></ul><ul><li>wkly should be given by DOT </li></ul>
    5. 5. TREATMENT OPTION 2 <ul><li>Initial Phase : </li></ul><ul><li> INH, RIF, PZA & either EMB or SM </li></ul><ul><li>QD X 2 wks, then 2 X wkly X 6 </li></ul><ul><li>wks </li></ul><ul><li>Continuation Phase : </li></ul><ul><li> INH & RIF 2 X wkly for 16 wks </li></ul>
    6. 6. TREATMENT OPTION 3 <ul><li>Treat with DOT 3 X wkly with INH, RIF, PZA, EMB or SM X 6 months </li></ul><ul><li>Strong evidence from clinical trials to be effective </li></ul><ul><li>Weaker evidence to D/C SM after 4 months if isolate drugs susceptible to all drugs </li></ul><ul><li>D/C PZA before 6 months is equivocal for 3 X wk regimen </li></ul><ul><li>No evidence of effectiveness of this regimen with EMB <6 months </li></ul>
    7. 7. ISONIAZID Adverse Reactions <ul><li>Hepatitis </li></ul><ul><li>Peripheral neuropathy </li></ul><ul><li>Lupus </li></ul>
    8. 8. INH ASSOCIATED HEPATITIS New York 1991 - 1993 <ul><li>Ten cases for liver biopsy </li></ul><ul><li>Eight on INH alone </li></ul><ul><li>Six (75%) female </li></ul><ul><li>Median age 33 </li></ul><ul><li>Three people < 20 years </li></ul>
    9. 9. ISONIAZID Monitoring <ul><li>Liver function tests </li></ul><ul><li>Clinical signs of hepatic </li></ul><ul><li>toxicity </li></ul><ul><li>CBC </li></ul><ul><li>Numbness/tingling of </li></ul><ul><li>extremities </li></ul>
    10. 10. ISONIAZID Drug Interactions <ul><li>Alcohol, Phenytoin, Disulfiram, Aluminum Salts, Carbamazepine, Benzodiazepines, Anticoagulants, and Ketoconazole </li></ul>
    11. 11. RIFAMPIN Adverse Reactions <ul><li>Hepatitis </li></ul><ul><li>Orange discoloration of </li></ul><ul><li>secretions </li></ul><ul><li>Drug interactions </li></ul><ul><li>Immunologic mediated </li></ul><ul><li>illness </li></ul>
    12. 12. RIFAMPIN Monitoring <ul><li>Liver function tests </li></ul><ul><li>Clinical signs of hepatic </li></ul><ul><li>toxicity </li></ul><ul><li>CBC, platelets, serum </li></ul><ul><li>creatinine, bilirubin </li></ul><ul><li>Bleeding abnormalities </li></ul>
    13. 13. RIFAMPIN Drug Interactions <ul><li>Warfarin, Digoxin, Beta-blockers, Ketoconazole, Verapamil, Quinidine, Methadone, Phenytoin, Corticosteroids, Oral Contraceptives, Dapsone, Theophylline, Sulfonylureas, Cyclosporine, Protease Inhibitors </li></ul>
    14. 14. ETHAMBUTOL Adverse Reactions <ul><li>Gout </li></ul><ul><li>Rash </li></ul><ul><li>Peripheral neuritis </li></ul>
    15. 15. ETHAMBUTOL Adverse Reactions <ul><li>Optic neuritis </li></ul><ul><ul><li>Central fibers of optic nerve decreased </li></ul></ul><ul><ul><li>visual acuity central scotoma </li></ul></ul><ul><li> green/red vision loss </li></ul><ul><ul><li>Peripheral fibers of optic nerve decreased </li></ul></ul><ul><ul><li>peripheral vision no loss of visual acuity </li></ul></ul><ul><ul><li>rare </li></ul></ul>
    16. 16. ETHAMBUTOL Optic Neuritis <ul><li>May be time & dose dependent </li></ul><ul><li>Rate reported at 0.8 - 6% at </li></ul><ul><li>accepted doses </li></ul><ul><li>At 30-40 mg/kg/d - rate may be </li></ul><ul><li>up to 33% </li></ul><ul><li>Visual loss may be irreversible </li></ul>
    17. 17. ETHAMBUTOL Optic Neuritis (Continued) <ul><li>May occur despite proper dose & </li></ul><ul><li>visual monitoring </li></ul><ul><li>May be delayed (months) or rapid </li></ul><ul><li>onset (days) after start of EMB </li></ul><ul><li>Role of zinc debated </li></ul><ul><li>May increase risk of optic neuritis if </li></ul><ul><li>zinc levels <0.7 mg/l </li></ul>
    18. 18. GUIDELINES BY THE JOINT TUBERCULOSIS COMMITTEE FOR PATIENTS ON EMB THERAPY <ul><li>Determine pretreatment renal function </li></ul><ul><li>Recommended dose and duration should not be exceeded </li></ul><ul><li>Record any history of eye disease </li></ul><ul><li>Pretreatment record of Snellen visual acuity should be made. Avoid EMB in patients with significantly reduced vision who may not notice further deterioration of vision </li></ul>
    19. 19. GUIDELINES BY THE JOINT TUBERCULOSIS COMMITTEE FOR PATIENTS ON EMB THERAPY (Continued) <ul><li>The patient should be told that EMB may affect vision and the drug should be stopped immediately if vision is further impaired. To guard against noncompliance, explain the small risk of this happening </li></ul><ul><li>Document that the patient has been informed about the risk of ocular toxicity with EMB </li></ul>
    20. 20. GUIDELINES BY THE JOINT TUBERCULOSIS COMMITTEE FOR PATIENTS ON EMB THERAPY (Continued) <ul><li>Patients complaining of ocular disturbances during therapy should be referred for a detailed ocular examination. EMB should be discontinued pending this examination </li></ul><ul><li>Routine visual acuity testing during treatment generally is not helpful in screening for ocular toxicity </li></ul><ul><li>Avoid EMB in patients with language or communication problems </li></ul>
    21. 21. ETHAMBUTOL Monitoring <ul><li>Visual acuity </li></ul><ul><li>Uric acid levels </li></ul>
    22. 22. ETHAMBUTOL Drug Interaction <ul><li>Aluminum salts </li></ul>
    23. 23. PYRAZINAMIDE Adverse Reactions <ul><li>Hepatitis </li></ul><ul><li>Gout </li></ul>
    24. 24. PYRAZINAMIDE Monitoring <ul><li>Liver function tests </li></ul><ul><li>Clinical signs of hepatic </li></ul><ul><li>toxicity </li></ul><ul><li>Uric acid levels </li></ul>
    25. 25. STREPTOMYCIN Adverse Reactions <ul><li>Auditory </li></ul><ul><li>Vestibular </li></ul><ul><li>Nephrotoxicity </li></ul><ul><li>Hypersensitivity </li></ul>
    26. 26. STREPTOMYCIN Monitoring <ul><li>Signs of Ototoxicity </li></ul><ul><ul><li>Vertigo </li></ul></ul><ul><ul><li>Ataxia </li></ul></ul><ul><ul><li>Hearing Loss </li></ul></ul>
    27. 27. STREPTOMYCIN Drug Interactions <ul><li>Loop diuretics </li></ul><ul><li>Neuromuscular blockers </li></ul>
    28. 28. ON THE LOCAL LEVEL <ul><li>Who treats TB here? </li></ul><ul><li>Who interacts with Health Dept. </li></ul><ul><li>here? </li></ul><ul><li>Who officially reports TB to Health </li></ul><ul><li>Dept.? </li></ul><ul><li>How is DOT arranged here? </li></ul><ul><li>Who has follow-up responsibility for </li></ul><ul><li>TB patients locally? </li></ul>